- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,698.24 / $2,089.30 / $2,511.89
| Facility | | $1,698.24 | $2,089.30 | $2,511.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,621.81 / $1,862.09 / $2,570.40
| Professional | | $1,621.81 | $1,862.09 | $2,570.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,202.26 / $2,818.38 / $3,548.13
| Professional | | $1,202.26 | $2,818.38 | $3,548.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $371.54 / $1,071.52 / $2,570.40
| Facility | | $371.54 | $1,071.52 | $2,570.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,548.82 / $2,041.74 / $3,467.37
| Professional | | $1,548.82 | $2,041.74 | $3,467.37 |